foley catheter insertion harm?

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We had a discussion at work tonight about the legal issues involved for RN's and UAP. I posted more specific details on this subject on the renal board. But, one of the things we were discussing is IF a PCT (who's done many in the past) inserts a foley into a pt (and works at a facility that provides training for this and it is part of their job description) ends up inflating balloon in the pt's urethra causing bleeding, etc., is the RN the one who is ultimately legally responsible for the PCT's error?

Some RN's said yes, others said no and the rest didn't know (with me among them).

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anyway...IMO and logically it would seem that if an institution has demonstrated that a person is trained and competent to perform a procedure the liabililty would lie with the operator. However...I guess it would also stand to reason that the PCT recognizing a problem would stop the procedure and seek out advanced expertise. Very similar to in a facility where a nurse runs into a problem and she calls someone with more expertise. I guess that would fall under reasonable judgement.

However, having been called to do many traumatic foleys I have not ever seen a long term complication from urethral or prostate foley that is left in for a short amount of time other than extreme discomfort until the problem is fixed.

Which leads me to my next point....the PCT should have recognized that if this man was not in distress and in pain prior to insertion that it was the consequence of the insertion that was causing a problem. And as we all know...a foley in the right place less any clot retention ususally is fairly painless.

I would like you like to know a legal opinion or someone who has been in this situation,.

Originally posted by Tory We had a discussion at work tonight about the legal issues involved for RN's and UAP. I posted more specific details on this subject on the renal board. But, one of the things we were discussing is IF a PCT (who's done many in the past) inserts a foley into a pt (and works at a facility that provides training for this and it is part of their job description) ends up inflating balloon in the pt's urethra causing bleeding, etc., is the RN the one who is ultimately legally responsible for the PCT's error?

Some RN's said yes, others said no and the rest didn't know (with me among them).

Gee, I wonder why the PCT didn't wait for urine return, even a drop, as we have all been taught to do?

I have to say, though, that I don't always wait for urine return, especially if there are no risk factors (i.e., BPH, previous prostate surgery, adhesions from previous instrumentation or gonorrhea, etc.--) but I always insert the full syringe of KY directly into the urethra and then insert the Foley CLEAR TO THE HUB, inflate with the full 10 cc, not 5cc, of water, then pull the catheter back until it stops on its own (can't pull back any further.)

Usually the KY alone can impede urine flow for a while, so you won't get an immediate return--if you are concerned, though, you can flush the catheter with H2O or NS, which will quickly remove the KY "plug" and allow immediate urine return.

Are you absolutely certain that the balloon was inflated in the urethra, and that is what caused the bleeding?

This is why I ask: a couple of years ago, several experienced OR nurses, myself included , had immediate frank blood return despite atraumatic insertion of a Foley--it happened to us when we were using a pre-packaged Foley kit that we had just started stocking. I cannot remember the manufacturer--it may have been Bard--and I think it was a silicone foley, not a latex one, as I believe we had gone to all silicone foleys to simplify things (getting rid of latex.)

When it happened to me, I knew I was "in the right place, " but there just happened to be a urologist out by the scrub sink, so I had him come in, just to double check. He checked, and agreed it was in the right place--irrigated, it was fine; left it alone.

Shorytly after, and in quick succession, it happened to several other nurses. I think they sent the remaining Foley kits back.

I stopped working there soon after (travel assignment) but I do stay in touch with the nurses there, so could probably find out what Foley kit this was for sure, so that you could check and see if it was the one used in the incident you wrote about.

p.m. me if you need this info.

And yes, I do think, at least legally, the nurse would be held ultimately responsible, if indeed this was an act that caused any permanent harm and was not due to a problem with the product--since we generally are responsible for the actions of those under our supervision. What does it say about the PCT/RN relationship in the P&P for this institution and for that unit, as well as according to the state nursing law of the state involved?

[QUOTE]Originally posted by stevierae
[B]Gee, I wonder why the PCT didn't wait for urine return, even a drop, as we have all been taught to do?

I have to say, though, that I don't always wait for urine return, especially if there are no risk factors (i.e., BPH, previous prostate surgery, adhesions from previous instrumentation or gonorrhea, etc.--) but I always insert the full syringe of KY directly into the urethra and then insert the Foley CLEAR TO THE HUB, inflate with the full 10 cc, not 5cc, of water, then pull the catheter back until it stops on its own (can't pull back any further.)

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Excellent point, Stevierae.

Presence of urine does not necessarily mean the catheter is inserted in the proper place. The current literature I've read cites that catheter tubing should be inserted "clear to the hub" as you state, then the balloon inflated with the amount of NS as indicated on the catheter port.

I just got an update on this. The urologist told the nurse mgr. that the PCT inflated the balloon in the pt's urethra PCT says he did not get any urine back after inserting & did not mention this or any discomfort, etc. to the RN. Urologist is trying to change hospital policy that only licensed personnel can insert foleys. Also heard that since PCT was "trained and competent" with prior experience placing foleys and "checked off" on this skill, that liability does not fall on the RN who delegated this task. Wheewwww,.....the whole thing would of made me nervous!!!

I remember learning in school that "you should always" have a return of urine if placement is correct. But then, after reading these posts I could see if tubing is inserted all the way, inflated, and pulled gently back until no resistance, that it is placed correctly. Our instructors reasoning was that the bladder is never fully empty and would retain some urine that would show up after placement.

Originally posted by Tory Also heard that since PCT was "trained and competent" with prior experience placing foleys and "checked off" on this skill, that liability does not fall on the RN who delegated this task. Wheewwww,.....the whole thing would of made me nervous!!!

I don't know if the fact that the PCTwas "trained and competent," as well as having been "checked off" on the skill, would hold up in court.

ALL the personnel under the RN's supervision--CNAs, LPNs/LVNs, PCTs, and, in the operating room, surgical technicians--are expected to be trained and competent, as well as having been checked off on vatious skills--otherwise they would not be there in the first place--but you can bet that it is the RN whose license will be on the line if the state nursing board steps in and investigates a situation like this--

Of course, in a med mal lawsuit, I am sure everybody would be named--the hospital, the patient's doctor, or doctors; the nurse; perhaps even the medical school the hospital is associated with if this is a teaching institution--they go after everybody; using the "deepest pockets" theory -- and I, as a nurse, would never trust my hospital to advocate in my behalf--I think it's wise for every nurse to carrry her own malpractice insurance in the event of incidents such as this--

I was an expert witness in a case a few years back in which the result from a foley insertion was a vaginal-rectal fistula, and the preteen girl was "voiding" liquid stool. Also, the patient had a latex allergy, and her perineum was extremely swollen and irritated.

From that case, I've implemented a few things into my own practice, including checking for a latex allergy before every foley insertion. Not something that I was taught, but certainly worth checking.
STG

Hello, haven't posted in a while but just had an interesting recent experience to pass along...

I just got called to see a man who was a quadrapalegic from MS. He had a large lower abdominal mass and due to his lack of sensation there was no evidence if this was painful or not. He was also very septic so his mental status was blunted. I was called ot see him for an elevated creat. of 5.9. We did a CT scan and it showed a 'fluid collection'.
It turns out his foley was in his urethra and his bladder had been displaced and was palpapble. Once it was removed (yes...it had been in that position for about 3 days...to the point he had become oliguic renal failure) and replaced correctly in a matter of 8 hours his creat. was 1.7

The speed bump was a man had stopped voiding and everyone assumed it was from sepsis and also attributed his low U/O to the same thing. In fact he was obstructed.

Take 5 minutes to do a bladder scan and be very aware the foleys in the prostate or urethra are more common than not.

Most hospitals do not allow PCTs or UAPs to do invasive procedures, such as foley catheter insertion, because of the liability risks. They do not have the background education to do such procedures. I would push to have this practice changed at your hospital.

The media are increasingly uncovering cases where errors made by unlicensed aides have resulted in harm to patients, including death. Most recently, Time magazine reported the case of Rebecca Strunk, a 46-year-old who died following a routine hysterectomy in 1994. Her family's lawsuit, which was recently settled out of court for $3 million, charged the Cincinnati, Ohio hospital with substituting nursing care with unlicensed technicians who lacked the knowledge, judgment, and skills to adequately assess and monitor Strunk's condition.